Saturday, July 26, 2008

NewFNP is no expert in mental illness, but she does know the difference between normal behavior and off-one's-rocker.

Here are behaviors which newFNP appreciates as falling squarely outside normal. Capturing pictures of the following subjects on one's cell phone camera: angels, fairies and elves who just hang out in one's bathroom mirror; heaven and hell (same picture); and men walking through clouds of fog on an urban city street. Also included in this list are movements so exaggerated that newFNP was genuinely concerned about a major musculoskeletal injury requiring a neck brace. And finally, a crescendo pattern to her speech on each and every subject addressed during the clinic visit - diabetes, soda, moms, returning to clinic the next day, etc.

This is a patient for whom her support staff tried to room without a chart - a diabetic patient whose sugar was 'HHH' and, according to newFNP's diagnostic skills, is schizophrenic. When newFNP finally got the chart, she reviewed the previous clinician's note, which noted in her general evaluation that she had an expressive personality. Expressive?!? Salvador Dali is expressive, this lady has severe mental illness.

A question which newFNP employs with some frequency is "Have you ever been under the care of a psychiatrist?" Readers will not be surprised to learn that this woman's answer was 'yes.' She told newFNP that she took Seroquel for two years after her mom died. In newFNP's relative inexperience, atypical anti-psychotics are not first-line for prolonged grief. NewFNP asked this woman if she thought she might need to resume her Seroquel treatment . Much to her relief, her patient replied that she thought this might be beneficial.

Psych referral completed! Now if newFNP could only get her diabetes under control.

Tuesday, July 22, 2008

NewFNP felt the magnitude of her decision to leave her clinic as she saw the crestfallen look on her clinic manager's face when she told him that her last full-time day is fast approaching. It's not that she didn't imagine that the transition from community health to academic medicine would be insignificant; it's just that she is ready to leave and has only been focusing on that. But to see this young man's shock and disappointment, to hear him say, the patients are really going to miss you to have him say that he is sad - ouch.

He also told newFNP, "But you are Franklin," the (fake) name of our clinic site. Maybe yes, but that's part of the problem. NewFNP just can't put her heart and soul into it any longer. It's too hard and the forces against change are too great.

"Two days?" he asked when newFNP told him that she would still be working part-time. "Can't it be three?"

It absolutely cannot. Somewhat sad though newFNP may be, she needs only to read her own blog to be reminded of what drove her decision.

NewFNP, apparently more of a pessimist than she had imagined, had feared that her medical director would be upset or feel betrayed or tell newFNP that it was all or nothing as she sat down with her today to tell her that she was hoping to stay part-time. Instead, she was the perfect mix of happy and sad - happy for newFNP that she has this new, exciting opportunity in academic medicine at a top ten university and sad to see newFNP go. She was absolutely supportive of newFNP staying two days per week and on newFNP's terms. She even hugged newFNP.

Did newFNP dream this? She hopes that the rest of the management team will be as supportive.

As newFNP goes through her days, seeing her patients and thinking about the patients for whom she has cared over the past three years, she feels a heaviness in her heart. She is choosing to give up being a primary primary care provider. She is making herself unavailable. She is choosing an amazing opportunity for career advancement, professional growth and day to day organization... all with meth addicts! But meth addicts who want to quit and who are enrolled in a Phase 2 clinical trial - a controlled environment indeed. She can walk or ride her bike to the clinic site. She doesn't have to be to work until noon, allowing plenty of time for hiking and gym and yoga and grocery shopping. Hell, she might even shave her legs more than once a week!

Although newFNP has been near tears thinking about making this change, it's the right decision.

And please, newFNP knows that this is off topic and that she has made this plea before, but can she please go on What Not To Wear?!?! Will someone please nominate her? She is starting a new job after all. And even though dressing well is religion to newFNP, even she has fashion ruts - hell, she has three white v-neck tees and lives in her Juicy sweats every weekend! Clinton and Stacy can tell her that she can still wear a pencil skirt even though her calves are thick and tattooed, they can tell her that she needs a new bra and they can drop her off in front of Theory with a $5000 visa card. Carmindy can teach her how to do the smoky eyes and Nick can teach her to coax her curls into ringlets. Please!! For the love of flattering trousers!!

Monday, July 21, 2008

When newFNP started this little blog, she had fully intended for it to provide some helpful hints to new NPs and NP students, rather than solely using it as a sounding board for complaints and to vent her own personal frustrations. To that end, newFNP would like to share a case with her readers.

As newFNP has previously noted, she really enjoys derm. It is something that other providers, however, fear and dislike. And newFNP understands - derm can be tricky and disgusting. When the skin goes south on you, it can really go south!! NewFNP works with one provider in particular who really dislikes derm and knows that newFNP really likes it. She consults newFNP routinely on her derm cases and newFNP happily examines and provides sage (she hopes) counsel.

This provider pulled newFNP into the room today to show her an extraordinary lesion. It was more than a lesion, really. It was a breast plate of erythematous papules and pustules on an otherwise healthy mid-twenties man. It was acneiform but newFNP immediately recognized that it was not acne. His face and the majority of his back were spared. There were no open comedones, nor were there nodules. It evolved rapidly over the course of two weeks. It was pruritic. His alcohol-based Mexican topical medicine was drying his skin, but not his pustules.

As newFNP's patients love to ask her, mostly when questioning newFNP about the mysterious etiology of a long-gone headache or tingly fingers or gas, "Porque sera?" Loosely translated, this means "Why could this be happening to me?" Often times, newFNP doesn't have an answer.

This time, she does.

NewFNP has her money on pityrosporum folliculitis, a condition caused by yeast and frequently misdiagnosed as acne. She'll let you know what the final outcome is, but she advised her colleague to check the patient's sugar and HIV status and to start him on a combination of topical (BID) and oral (200mg QD x 30 days) ketoconazole. Clinical improvement with the anti-fungals supports the diagnosis.

This is so one of those cases in which newFNP should have snapped a picture with her camera phone and sent in the case to a journal. But newFNP didn't think of that at the time. Son of a bitch!

Wednesday, July 16, 2008

A while back, newFNP saw a guy who came into the clinic and was quite distressed about the painful ulcer he had on his penis. He somewhat bashfully showed newFNP the lesion which required him to retract his foreskin. What was revealed was a bright purple glans with a single ulceration.

The first time newFNP saw the purple liquid covering something or other, she was quite surprised. Tincture of violet, or violeta, is a much loved antiseptic in the Latino community. NewFNP's patients don't seem to use it as advertised in the natural stores - as a tincture of be consumed - but rather paint it on any manner of superficial injuries including, it seems, the ones that show up on the penis.

Despite the violeta, newFNP did a herpes culture - negative - as well as a syphilis test - also negative. Her patient wasn't giving up any clues as to what may have caused this ulceration. No zipper misjudgment, no history giving newFNP a single damned clue about why his penis had a big fat ulcer.

Well, newFNP's colleague elicited a story that is incredible. She saw this gent for follow-up, penis still purple and ulcerated. According to her, he must have felt like confessing because he told her how he got the ulcer.

NewFNP knows this man to have been a former crack user. Apparently, he had been a crack dealer as well. His storage space: the cozy area between his foreskin and his glans.

Is that even possible? There is no drawstring! How does the crack stay there? Not having a little foreskin pouch of her own, newFNP frankly just does not understand. But if it's true, that is gross. And apparently very dangerous. And yet another reason to add to the 'con' column when considering crack smoking!

Dr. Dual-Ivy-League-Degrees had a good point about this one - the most important question in the history is often, "What do you think might be causing this?"

Saturday, July 12, 2008

iWhen newFNP was in grad school, she had a dear friend - who shall remain anonymous - who visited an out of town ex-boyfriend under the pretenses of rekindling an old romance. Upon arrival, it became clear to her that she was not going to having any knight in shining armor moments with this guy. Why? Because despite the fact that she flew some distance to see him, he had made plans with another ex-girlfriend for the same frigging weekend! When her pal called, incredulous, and related the story to newFNP, newFNP came up with a plan.

"OK," newFNP said, "While he is at out of the house, go to the grocery store and buy some frozen fish. Put it under his couch right before you leave. By the time he realizes where the hideous smell is coming from, you'll be long gone and his couch will stink to high heaven!"

Evil? Sure. Fantasy revenge plot? Definitely. NewFNP's friend, however, is far too kind to engage in such behavior and simply changed her flight home for an earlier departure and removed this guy's name from her cell phone.

Imagine, then, being 32 weeks pregnant and discovering that your husband of twenty years, with whom you have four daughters, has not only been with another woman for three years, but has fathered two more children by her! When you come into newFNP's office with that, newFNP is very sympathetic.

NewFNP knows that research shows that a two-parent family is better for children. But it seems like a tough pill to swallow to expect someone to stay with a lying sack of shit just for the sake of the kids. Is it too much to ask people to just grow a pair and respect their relationships? If people have decided that outside relationships are cool, then great - have at it. But that is not the understanding this woman had regarding the expectations of her marriage.

She gave him one month to decide what he wanted to do, which is about 30 days, 23 hours, fifty-nine minutes and fifty-nine seconds more than newFNP would have given him before his boxer shorts, shaving cream and nose hair trimmers were out on the front lawn.

But this woman is in a real conundrum. They have a $3400/month mortgage payment. Fannie Mae, Freddy Mac, Indy Mac! Do you hear newFNP, you fuckers! Do not give mortgages to people who cannot afford them. And $3400 to live in the shitty area where newFNP works? Does the house come with bars on the windows and an alarm system and an armed guard and a pit bull and a rottweiler? No fucking thank you.

NewFNP never ceases to be surprised when her patients tell her about their crazy expensive mortgages. How in the hell do her patients afford houses when newFNP can barely afford her 1-bedroom apartment? It kills her every time. Granted, her patients did not spend nine years in college and grad school but still. Fuck! NewFNP wants a house and a pool and a dog. Damn!

OK, back to the patient. Obviously, she was distressed. She is 32 weeks pregnant and has lost five pounds in the past month. She was crying as she recounted the tale to newFNP. NewFNP asked her what she wanted. She replied that she wanted him to tell their daughters why he was leaving and then she wanted him to leave.

Forever attempting to be culturally aware with her Latino population, newFNP said,"Well, you can always put hot sauce in his underwear." She laughed - hard. Sometimes it just helps to imagine it.

Thursday, July 10, 2008

NewFNP is a broken frigging record. She is burnt out. No, she is charred. She is unrecognizable.

She has, however, had some lovely encounters lately that have re-affirmed her love for nurse practitionering. Her post-partum patient who was thrilled to introduce her newborn baby to newFNP, who had done the vast majority of her prenatal care, and who told newFNP that she wold help care for newFNP's baby when she finally got around to having one; the physical exam with a lovely woman who gave newFNP a big hug in the hallway and could be heard telling other staff members how happy she is with the care she receives at the clinic; the mom who entered the exam room so angry after having waited for hours to have her daughter's ear examined who left with questions answered and hope that her daughter's chronic condition will be solved; the overwhelmed patient for whom an IUD is a real life-saver.

She was so thankful to host nhFNP and nycPNP a couple of weeks ago and not only because of the crazy delicious tapas and wine! Theses ladies graduated with newFNP three years ago. Both are on their second jobs - various aspects of their respective first jobs having chewed them up and spit them out. Both are happy and thriving in their new positions. One even presented her work at a major conference recently.

If newFNP were to present her work somewhere, it would be like an avant-garde show involving lots of crying while in the fetal position, some throwing up, and monkeys throwing loads of crap at her. That is not how newFNP wants to have her work represented.

NewFNP is struggling with the thought of leaving community health. She takes a lot of pride in her work and she has a real love for her patients. But the utter lack of a system is killing her. Perhaps she will be able to maintain her sanity if she is only entrenched in the mire of her clinic part-time.

And, just as importantly, she can't really leave full-time community health practice... whatever will she write about if she leaves entirely?!?!

Thirty-six work days until she can go. Thirty-five if she gets a UTI or an otitis or something. Nothing serious, of course. Just something a little trip to the day spa would cure!

Thursday, July 03, 2008

NewFNP has had more than one request for advice as to what in the hell to take to your first job. NewFNP figures that, given the season, at least a few other people may have the same questions. So here we go.

The Basics:

Obviously, stethoscope and DTR hammers and your brain fall into the 'crucial' category.

White coat - maybe. Depends on the practice. NewFNP has forgone hers entirely although sometimes misses its plentiful pockets in which she would jam all manners of clinical provisions, thus leading to a very unflattering hip-spread look.

A PDA or, at the very least, a calculator are helpful all day long when faced with '80-90 mg/kg/day in divided doses' calculations.

Your physical assessment book. NewFNP still refers to hers, especially for the not often used tests and for neuro assessment.

Two phone numbers: the person you can reasonably ask your most shameful question - something that you absolutely should have learned in school but were too busy playing Brickbreaker on your BlackBerry and you missed it, and someone who you know is intelligent and experienced and will help you with your tough cases.

Snacks. Both carbohydrates and proteins.

Diet soda/coffee/tea. Caffeinated. Water. NewFNP still rocks the Nalgene as it was a gift from a VIP in her life, but the stainless steel are now considered the de rigueur water bottle.

The Oh Yeah - Good Ideas:

A derm book - Habif is the best but Fitzpatrick is acceptable, less spendy and has a wealth of information in a paperback form.

A ruler for measuring positive TB tests and derm lesions.

Good pens. Yes, your clinic will provide you with pens if they are not yet equipped with EMR. But these pens will suck and hurt your sensitive fingers. NewFNP has the ugliest writer's bump and she has had it for years because she holds her pens hard. But now she has comfort-grippy pens and her writer's bump isn't quite so Quasimodo-esque.

Pregnancy and BMI wheels. Yes, they are on your PDA but frankly, it's quicker to just use the old wheel system.

The Sanford Guide, not to be confused with the Sanford & Son guide, which is probably a lot funnier. NewFNP has an appreciation for The Guide which she must admit to having lacked while in school. She's considers herself a convert.

The After Clinic must haves:

NewFNP knows that not everyone drinks and she doesn't want to be an advocate for alcoholic beverage consumption, but in her experience, a nice glass or two of a delicious red goes a long way in the Calgon-take-me-away type of relaxation. She likes L'Automne and Roessler La Brisa and Fratelli Perata, but there are tons out there! Find a good one and buy a case. And a rabbit-style opener. Why struggle?!?

Exercise. For stress reduction and to work off those donuts/cookies/cinnamon rolls that are ironically always around health clinics.

Support. Your first job is hard. You need to have friends and partners and family to take care of you when you are taking care of your patients.

Your personal swears. Everyone has them. Not all of them are as colorful or as plentiful as are newFNP's but they're all good and effective! You'll need them.

And the most important thing to take to your new job:

A sense of humor. Without it, you are three ways to Sunday, up a creek without a paddle, take no prisoners, no joke fucked.

Wednesday, July 02, 2008

Just when newFNP was reconsidering her decision to go into clinical practice, she was privileged/mandated to attend a conference for a quality care collaborative in which her clinic participates. There are only three providers who are currently working within this collaborative; the first two attended day 1 of the session whereas newFNP held day the fort on day 2.

It was about as pleasant as being waterboarded.

NewFNP does not want to create PDSA cycles ever, ever again. She does not want a valid plan to be that an MA is going to put a specific form in a specific place. That is not a plan for which one should need to devote time, energy or a written plan for action documented on duplicate forms. She certainly does not want to evaluate that plan in clinic.

One of newFNP's plan involved three data collection points. She was chastised for that being too much. Three? Too much? In the course of a ten-month condition which is handily broken up into trimesters? It seems like we're all selling ourselves short if that is too much.

NewFNP was so happy to see her diabetics and prenatals and well-child visits today. It's nice to be reminded that one's job could be to do PDSAs or be a in a cubicle analyzing god-knows-what or working in the home appliance department at KMart or something like that.

NewFNP will take the challenges and rewards of clinical practice any day, although she wouldn't mind a little time for computer Tetris every now and then!

This blog is for new NPs or NP students who want some real 411 on the life of a new practitioner. A new practitioner in a busy, understaffed, urban community health clinic in a major metropolitan area. Oh, and newFNP swears while writing and, sometimes, while working although she tries to keep those swears to herself. Consider yourself warned.